Healthcare Access Challenges and Facilitators for Back Pain Across the Rural-Urban Continuum in Saskatchewan, Canada: Cross-Sectional Results From a Provincial-Wide Telephone Survey

Background: Chronic back pain is a common musculoskeletal disorder, disproportionately affecting rural and Indigenous people. Saskatchewan has a relatively high proportion of rural and Indigenous residents; therefore, understanding barriers and facilitators to accessing healthcare are needed to improve healthcare service delivery. Methods: A provincial-wide telephone survey explored experiences and perceived healthcare access barriers and facilitators among 384 Saskatchewan residents who experienced chronic low back pain. Chi-squared tests were performed to determine if people who lived in urban versus rural areas differed in the proportion who had accessed services from various healthcare practitioners. T-test and Mann-Whitney U analyses were conducted to determine differences between urban and rural, and Indigenous and non-Indigenous respondents. Results: Of 384 residents surveyed, 234 (60.9%) reported living in a rural location; 21 (5.5%) identified as Indigenous. Wait times (47%), cost (40%), travel (39%), and not knowing how to seek help (37%) were the most common barriers for Saskatchewan residents seeking care, with travel being the only barrier that was significantly different between rural and urban respondents (P ⩽ .001). Not knowing where to go to access care or what would help their low back pain (P = .03), lack of cultural sensitivity (P = .007), and comfort discussing problems with health care professionals (P = .26) were greater barriers for Indigenous than non-Indigenous participants. Top facilitators (>50% of respondents) included publicly funded healthcare, locally accessible healthcare services, and having supportive healthcare providers who facilitate referral to appropriate care, with urban respondents considering the latter 2 as greater facilitators than rural respondents. Telehealth or virtual care (P = .013) and having healthcare options nearby in their community (P = .045) were greater facilitators among Indigenous participants compared to non-Indigenous respondents. Conclusions: Rural, urban, Indigenous, and non-Indigenous people report overlapping and unique barriers and facilitators to accessing care for chronic low back pain. Understanding perceived access experiences will assist in developing more effective care models for specific communities or regions.


Health Services Insights
Chronic back pain can negatively impact both individuals and the broader health system due to the resource intense care needs for patients. For example, it has been shown that patients who experience chronic low back have high rates of primary physician care visits, 3 specialist consultations, diagnostic procedures, 4 and opioid use, 5 among others. Improving access to non-pharmaceutical back pain treatment options, like physiotherapy care, is an especially important public health issue in Canada in the midst of the current opioid crisis, given that early access to physiotherapy care among people with back pain can lead to substantially reduced (up to 89%) likelihood of opioid use. 6 Despite emerging evidence highlighting reduced access to appropriate care among Canadians with chronic back pain, 7,8 there is a sparsity of research focused specifically on rural, remote, and/or Indigenous populations in the Canadian setting. 9,10 In Saskatchewan, 32% of the population lives in rural and remote areas 11 and 17% (187 885) of Saskatchewan residents are Indigenous. 12 Saskatchewan falls within the Métis Nation Homeland, where numbered treaties are encompassed by the land of the province. Lower numbers of practitioners specialized in the management of musculoskeletal pain, such as physical therapists (PTs), are available in rural areas. 13,14 Both rural, remote, and/or Indigenous populations are approximately 30% more likely to have chronic musculoskeletal issues such as chronic back pain. 15 There are complex historical, psychosocial, cultural, and environmental factors that influence general health and wellbeing among Indigenous (Various definitions of Indigenous appear in research literature. Within the scope of this paper, "Indigenous" refers to unique and different population groups including First Nations and Métis peoples, acknowledging the inherent limitations of this definition.) people, which are intertwined with barriers and facilitators to accessing healthcare. 16 There are multiple clinical guidelines providing similar recommendations for managing low back pain; however, a substantial gap persists between evidence and practice. 17 Current recommendations for opioids for chronic non-cancer pain 18 and low back pain in Canada 19 include referral to multidisciplinary or non-physician care providers such as physiotherapists or chiropractors. However, given documented access barriers to these services and other issues related to feasibility of implementing guidelines, they become challenging to follow in many clinical contexts. 20 Although potential barriers to healthcare access among Canadians with chronic back pain have been identified through population-based secondary data analysis 7 and through qualitative exploration of focused population groups (eg, farmers, 21 spinal triage service, 22 ), no study has evaluated both barriers and facilitators of access to care between rural and urban residents in Saskatchewan, as well as Indigenous and non-Indigenous people. Having a better understanding of the barriers and facilitators that are unique to these populations may assist in developing more successful care models for people living with chronic low back pain. This study aimed to determine the perceived healthcare access barriers and facilitators among people who live with chronic back pain in Saskatchewan, and determine if differences exist among urban and rural residents, as well as Indigenous people.

Methods
This was a cross-sectional population-based phone survey, part of a multi-phase study with detailed methodology previously published. 23 Participants included Saskatchewan residents, 18 years of age or older, who had experienced lower back pain (defined as pain localized between the bottom of the rib cage and the bottom of the buttocks, that may or may not include leg pain) for at least 3 months. The Canadian Hub for Applied and Social Research (CHASR), University of Saskatchewanbased research support and consulting service, conducted a random probability telephone survey from May 5th to May 25th, 2022. An estimated sample of 383 was based on: the estimate that 20% of the adult population has chronic back pain 15 ; the adult population of Saskatchewan according to most recent Census data 24 (843 975); and a margin of error of ± 5.00%.
Oversampling of rural areas was performed in order to reflect the higher prevalence of CBP. 15,25 VoxcoCATI software was used to dial telephone numbers at random. Telephone numbers were called up to 5 times without a response before the number was discarded. Participants were asked demographic questions, as well as experiences in health care access and use for their chronic low back pain. Findings from concurrent qualitative research 23 examining barriers and facilitators to healthcare in Saskatchewan for chronic low back pain informed the development of our population-based phone survey questions focused on exploring perceived health care access barriers and facilitators among rural, remote, and urban patients with chronic back pain, with the opportunity for participants to report Indigenous status (Appendix 1). A comprehensive review describing the complex factors influencing general health and wellbeing among Indigenous people is beyond the scope of this manuscript; however, our commitment to understanding the unique needs of Indigenous people in Saskatchewan to further a respectful partnership with and among Indigenous community members is aligned with, and informed by, the United Nations Declaration on the Rights of Indigenous Peoples (UNDRIP) 26 and the TRC Calls to Action. 27 Our research approach is further described in our overarching protocol. 23 The phone survey questions included both closed and openended questions. Descriptive analysis was conducted for demographic variables, as well as duration of back pain and health care services accessed for back pain. Chi-squared tests were performed to determine if people who lived in urban versus rural areas differed in the proportion who had accessed services from the listed health care practitioners. Responses to barriers were on a 4-point unimodal and symmetrical interval ranging Crockett et al 3 from not at all a barrier, a minor barrier, a moderate barrier, to a serious barrier. Responses to facilitators were on a 4-point interval ranging from not at all a help, a minor help, a moderate help, or a major help. Given that data were normally distributed and with equal variances for majority of the variables, T-test analyses were conducted on all normally distributed variables with equal variances to determine if urban and rural respondents differed in the extent to which they faced barriers in getting the care they need for their back pain, and if there were any differences in facilitating factors in accessing care for their back pain. 28 For the variables that were not normally distributed, Mann-Whitney U tests were conducted. The same methodology was used to determine if Indigenous and non-Indigenous respondents differed in the extent to which they faced barriers or facilitators in getting the care they need for their back pain. Although formal qualitative analysis was not completed, participant quotations were collected to highlight key findings from quantitative analyses.
Ethical approval for this research was provided by the University of Saskatchewan Behavioural Research Ethics Board (Beh REB #1973).

Results
The survey generated a response rate of 12.6% and resulted in 384 completed interviews among randomly-selected Saskatchewan residents who have been experiencing low back pain for at least 3 months (ie, over 3000 people were contacted, with 384 people choosing to participate). Descriptive characteristics are reported in Table 1. One individual did not disclose rural vs urban residence, so was removed from analyses.
Health care practitioners from whom participants received care for their low back pain are reported in Figure 1. Seeing a family physician for their back pain was most common (84.9%), followed by a chiropractor (71.4%), physiotherapist (68.5%), and massage therapist (67.4%). More than half of respondents had accessed services from at least one of those 4 health care practitioners. Almost all the respondents (89.6%; n = 344) had taken over the counter medication (eg, Tylenol, Advil) and more than half (58.6%; n = 225) had taken medication prescribed by a health care provider.
Chi-squared tests revealed that significantly more urban respondents had accessed care for their back pain from family physicians, physiotherapists, and community supports ( Table 2).
For health practitioners from whom respondents had not received care, respondents were asked to indicate why not. Suggestions of possible reasons included cost, wait time, travel time/location, a lack of interest, or they could provide their own response that did not fall into one of those categories. A lack of interest was the most common reason for not accessing services from all listed health care practitioners, with the exception of surgeons/specialists where not receiving a referral was the most common barrier (12.8%, n = 53), followed by the belief that their back pain was not bad enough (7.4%; n = 28) (Percentages reported are a proportion of all respondents.). Not having a family physician was the most common "other" reason for not accessing a family physician (3.4%, n = 13), with this being a greater barrier for rural respondents (rural: 4.7%, n = 11; urban: 1.3%, n = 2). Cost was a notable barrier for receiving services from physiotherapists (5.5%; n = 21), massage therapists (5.5%; n = 21), community supports (4.7%; n = 18), exercise therapists (4.4%; n = 17), acupuncture providers (4.2%; n = 16), and chiropractors (2.6%; n = 10). Not having access to care services provided by a particular healthcare practitioner/service also was a significant barrier in relation to community supports (21.6%; n = 83), exercise therapists (10.4%; n = 40), Indigenous or traditional healers (10.4%; n = 40), and acupuncture providers (8.1%; n = 31). Lack of awareness about the care provided by a health care practitioner impeded access to Indigenous and traditional healers (24.0%; n = 92) and exercise therapists (12.5%; n = 48).

Barriers
We investigated whether barriers to care were similar in both urban and rural participants. Rural respondents reported travel to access health services, t(338) = −7.51, P < .001 (urban: M = 1.59, SD = 1.03; rural: M = 2.45, SD = 1.15) to be a greater barrier than urban respondents ( Figure 2).
T-test analyses revealed that Indigenous respondents report not knowing where to go or what will help, t(373) = 1.91, P = .03 (Indigenous: M = 2.60, SD = 1.14; non-Indigenous: M = 2.09, SD = 1.17) to be a greater barrier than non-Indigenous respondents.

Facilitators
A t-test analysis of urban and rural differences on facilitators to receiving care for back pain revealed that urban respondents consider health care nearby in their community, t(371) = 3.06,  *An option for gender identity was provided. Three participants selected "other" but did not specify their gender identify beyond this. **Within the scope of this paper, "Indigenous" refers to unique and different population groups including First Nations and Métis peoples. SD = 1.10; non-Indigenous: M = 2.64, SD = 1.21) to be greater facilitators than non-Indigenous respondents. The survey items were predominantly quantitative with some open-ended questions. Formal qualitative analysis did not take place. However, quotes highlighted key findings (Table 3).

Discussion
A telephone survey of 384 Saskatchewan residents with chronic low back pain was completed in May 2022. Respondents indicated the type of health care services they had accessed, what barriers to access they have encountered, and what factors serve as facilitators to accessing care for their back pain. Many barriers and facilitators were common among urban and rural residents, but there were some differences. For example, rural respondents were less likely than urban respondents to have accessed care from family physicians, physiotherapists, and community supports. Rural respondents also encountered a greater barrier in relation to the need to travel to access health care services. Rural respondents were also less likely than urban respondents to perceive "nearby health services and providers who help them get care" as a facilitator to their care. Indigenous respondents reported a greater barrier to accessing care based on not knowing where to go or who to access for their chronic low back pain, cultural sensitivity, and comfort in discussing their problems with healthcare professionals. These findings are in line with prior research demonstrating increased likelihood of having chronic back pain among those living in rural or remote areas of Saskatchewan and Indigenous people, 25 combined with reduced availability of musculoskeletal healthcare providers in rural and remote areas of Saskatchewan, 14 and ongoing evidence of systemic racism existing in our healthcare system. 29 For most Canadians with chronic back disorders, a family doctor is their primary point of contact within the health-care system, with a majority of Canadians only seeking care from a  Health Services Insights family doctor and not accessing care from a musculoskeletal care provider like a physiotherapist. 7 Our result is consistent with this, as most participants have accessed a family physician (84.9%), with rural respondents less likely to have accessed a family physician, but still fairly high rate of access. Among older respondents (mean age of 68.6 years), with longstanding persistent pain (more than half of respondents experiencing low back pain for at least 10 years), it is not surprising that respondents will have had more experience in accessing various providers and during different iterations of the health care system. However, with more recent system changes, the Canadian Medical Association has acknowledged a "critical" family physician shortage, leaving 1 in 5 Canadians without a family physician. 30,31 Contrary to 84.9% of participants stating that they have accessed a family physician, the most frequent barrier to accessing a family physician was that respondents did not have a family physician. This was more problematic with rural respondents and likely underreported in our data since it was not explicitly asked, but rather reported voluntarily as an "other" reason for not accessing a family physician. With a growing population that is increasing in age, and experiencing more chronic health concerns, it is becoming more difficult for family physicians to meet the diverse needs of patients. 32 Given the Canadian primary care crisis, 33 it is becoming more important to focus and invest in further development of team-based models of care 33 or non-physician led models that have been shown to improve wait times and patient outcomes for low back pain care. [34][35][36][37] There are few known interdisciplinary care models focusing on addressing the unique needs and context of rural or Indigenous communities in Saskatchewan and Canada. 10 Many people with low back pain are still uncertain how to access non-pharmaceutical care without the guidance of health care providers like family physicians. Secondly, research has demonstrated inadequacies in our healthcare system including bias in pain assessment and treatment recommendations and    consistent evidence of inequities based on colonization and systemic racism that can lead to avoidance of care. 29,38 Consistent with prior research, 21 wait times and costs emerged as the most common barriers among survey respondents with approximately 47% and 40%, respectively, respondents indicated that not knowing which services they should access or what will help was found as a significant barrier (37%) to accessing care for low back pain across urban, rural, remote, as well as Indigenous populations, with some Indigenous participants reporting that they did not feel healthcare providers believed their reports of pain. Indigenous respondents felt that the lack of cultural sensitivity among practitioners, and not feeling comfortable discussing their pain with their healthcare providers were barriers to accessing care. Although this research did not explicitly examine racism in healthcare, there is an important need to consider models of care and health care policies in ways that redress racism and mitigate harm for Indigenous peoples accessing care for low back pain. 29 A main facilitator to accessing healthcare was having a healthcare provider who helps to get care (34.6% of respondents), providing appropriate referrals or educating on existing services that are appropriate at the right time. This is in line with current research in Saskatchewan where chronic pain patient expressed challenges with navigating the health system. 39 Further research is needed on how best to educate the public and healthcare providers on anti-racism in healthcare, evidence based guidelines, and existing care options for chronic low back pain. 40,41 Where appropriate, this could be without the need to first access a family physician or waiting to see a specialist to initiate care. 6 Accessing a physiotherapist as a first point of contact has been shown to result in lower utilization of high-cost medical services, as well as lower opioid use. 6 For many Saskatchewan residents, accessing a physiotherapist is not possible due to associated travel or cost barriers. A 2017 report from the CLHIA-Canadian Life and Health Insurance Association 42 estimates that 25 million Canadians have extended health care benefits. However, many patients in Canada still pay out of pocket for community-based, non-pharmacological services, such as those offered by physiotherapists, chiropractors, and psychologists when particular services are not covered or when certain benefits have been exhausted. Universal health-care coverage is typically limited to some prescription medications, diagnostic imaging, or referral to publicly funded medical specialists. 8 In addition, remote Indigenous people have added jurisdictional challenges to the complexities to accessing care from musculoskeletal providers, as there is no funding for physiotherapy outside hospitals under Non-Insured Health Benefits (NIHB). 43 All combined, this creates an issue of inequitable access, where not all patients can afford long-term treatment to manage chronic pain, particularly patients who are low-income or do not have private health insurance. These factors perpetuate inequities in low back pain experiences and outcomes among Indigenous peoples. When asked about facilitators to getting the care they need for their back pain, more than a third of respondents indicated that publicly funded health care (41.1%) was a major help.
Most respondents had accessed services from a range of different health care practitioners; most commonly, respondents accessed health care services from family physicians, chiropractors, physiotherapists, and massage therapists, with access rates ranging from 65% to 85%. Common reasons for not accessing certain health care services included a lack of interest in that service, not having received a referral, costs, not having nearby access, and a lack of knowledge or awareness of a particular service or health care provider, with the most common response Crockett et al 9 being a lack of interest. This may be related to other associated barriers over the long-term, leading to "giving up" or may be related to a lack of awareness, as illustrated by these quotes from respondents: "I don't think they can do anything"; "They can't do anything, it's the bone, not much they can do"; "No solution at the moment." Other participant responses associated with being not interested in certain providers were related to already having accessed a different provider, relying on self-management strategies with majority describing self-guided coping strategies, or simply that they don't think that specific practitioner would help. Some quotes: "Saskatchewan doesn't have access to healthcare like that." (referring to physiotherapy, which is available in Saskatchewan). These examples demonstrate an implied lack of awareness; however, majority of respondents indicated that they were not interested without providing any further explanation. This response requires further investigation into the complexity associated with not being interested, relative to other existing barriers, as well as current state of their chronic back pain and appropriateness of various services given individual circumstances.
The need to travel to access services also emerged as a substantial barrier overall (39%) and was a greater barrier for those living in rural areas of Saskatchewan. This is not surprising, given the limited distribution of physiotherapy services in rural and remote Saskatchewan and lower use of these services among people living in rural communities. 7,14,44 On the other hand, having healthcare nearby that did not require extended travel time was a major facilitator for 34.9% of respondents. A hub and spoke model of care has been demonstrated to be an effective model of care for chronic pain, providing core services within communities, or at the spoke. 45 Hub and spoke models are starting to integrate videoconferencing within the model of care, with ongoing efforts in establishing toolkits and other resources to enhance this model to care. 46 Despite recent research demonstrating the value of virtual care in certain contexts, telehealth/virtual care rated lowest among facilitators with our respondents, with 48.2% of the sample indicating it was not at all a help. Virtual care has been shown to be an effective way of providing assessment and care for chronic low back pain [47][48][49] ; unfortunately, many respondents perceived this question as a telephone call and majority of the respondents indicated that phone call appointments were occurring due to the COVID-19 pandemic. In Saskatchewan, Telehealth is defined as "linking patients to health care teams using highly secure videoconferencing technologies." 50 This survey was deployed during the COVID-19 pandemic, when phone consultations were becoming a predominant method of care provision with family physicians, with 58.2% of care being provided over the phone as of January 2021. 51 It is also possible that some respondents did not have the opportunity to access telehealth or virtual care given the reported duration of symptoms and virtual care being an emerging platform for care provision 52 ; therefore, this response may reflect a lack of availability of virtual care versus a negative experience with virtual care. The nature of the phone survey did not allow for clarification of this finding. This should be further explored with future research, and future research should clearly distinguish phone consultation versus videoconferencing. Despite these limitations to our study, Indigenous respondents reported that telehealth or virtual care was one of the main facilitators to accessing care, with almost 30% of all respondents indicating that it was a moderate-major help to accessing care. Virtual care allows Indigenous people living outside urban centers to remain in their community, where they can be surrounded by family, language, and important cultural supports through their chronic pain experience when they may feel the need for enhanced support from family members. Given the rapid uptake of virtual care in response to the COVID-19 pandemic, practitioners must now consider the format of care provision post-pandemic (ie, in-person, video, telephone) to ensure optimal patient outcomes. 53 With virtual care as an emerging area of practice, 52 further evidence is needed to establish quality improvement measures, appropriate training for practitioners including cultural responsiveness and anti-racism training and policies, as well as clinical guidelines in order to provide assurance for patients that they are receiving high quality, equitable care.

Strengths and limitations
This population-based study had a number of notable strengths. First, there was strong sampling methodology applied, with community-informed questions integrating principles of patient-oriented research. The study captured some of the shifts in care related to the COVID-19 pandemic, which is realistic of current healthcare provision and capturing current experiences. However, there were several limitations to consider as well. The nature of the telephone survey relied of selfreport and perceived contributors to accessing healthcare. Our response rate is likely an underestimate, as some respondents who refused to participate may not have qualified (ie, did not have back pain) had they progressed to the point in the survey where interviewers could ask them eligibility questions. Although we determined the sample size a priori based on the estimated prevalence of chronic back pain, the data analyses (eg, comparing rural vs urban and Indigenous vs non-Indigenous) may have a risk of type I errors, given the multiple tests included. To further elucidate these relationships, future research should be done with larger sample sizes. Since only 5.5% of the respondents were Indigenous (17% of the Saskatchewan population is Indigenous); the sample underrepresents the Indigenous population in the province. The nature of the phone survey may not have allowed time and space to build the trust and rapport necessary for individuals to share the true depth of their experiences, especially as they relate to systemic racism in healthcare. Further community-led research is needed to ensure Indigenous experiences are understood, so appropriate and relevant advocacy and care can be developed to enhance equitable access to culturally responsive services. In addition, the nature of the phone survey did not allow for discussion, clarification, or follow-up questions on responses to address assumptions or perceptions on the meaning of survey questions. For example, based on responses, it was clear that the question on telehealth/virtual care was influenced by the COVID-19 pandemic changes in provision on care, and many participants responded in a way that reflected phone consultation care as a response to the pandemic. Despite the limitations, future research can build on the knowledge gained in this phone survey to further explore these barriers and facilitators to accessing healthcare for Saskatchewan residents.

Conclusion
Our findings suggest that rural Saskatchewan residents are not as easily able to get the same types of care for their back pain as urban respondents. They face greater barriers and have fewer facilitating factors. Our findings further suggest that Indigenous people have unique barriers to accessing care, including not knowing where to go or who could help with their low back pain and experiences with providers demonstrating lack of cultural sensitivity. Indigenous people may experience chronic back pain in diverse and unique ways that may be different from the general population. 16 Understanding the unique needs of Indigenous people in Saskatchewan to further a respectful partnership with and among Indigenous community members is aligned with, and informed by, the United Nations Declaration on the Rights of Indigenous Peoples (UNDRIP) 26 and the TRC Calls to Action. 27 Obtaining a greater understanding of the unique characteristics, strengths, needs, and challenges impacting Indigenous people is important as we collectively work to decrease health inequity gaps and decolonize health care practice to better meet the needs of Indigenous people living in Saskatchewan. Future research should consider the unique needs of rural, remote, and Indigenous people, building on known facilitators and barriers to accessing healthcare for low back pain, to develop models of care that can specifically prioritize community-directed and culture-based strengths. Improving our understanding of perceived access barriers across the Saskatchewan population will assist in developing more effective care models that address the gaps between evidence-based guidelines and healthcare practice patterns and inform practices and policies more broadly for other geographical regions with relatively high proportions of rural and remote dwellers and Indigenous peoples.